IDENTITY

Name : Child. F
Age : 23 months
Sex : Male
Address : Baruga
Admission : March, 5th 2017
(01.30 PM)
DPJP : dr. Syamsul Rijal,
Sp.B
 HISTORY TAKING
Chief complain : Burn wound
Anamnesis :
Patient presented with the complaints of
burn wound since one hour before
entering hospital because scalded.
Mechanism of trauma : the patient was
playing at home. When he run to the
kitchen, suddenly he crashed into a frying
pan containing boiling chiken broth, so
that the boiling water spilled on the
patient body.
 Primary survey
A Clear

RR 30x/min, spontaneous
thoracoabdominal type, symmetrical B
C Pulse =110x/min, regular, strong

GCS 12 (E4M4V4), pupil isochors,

: 2,5mm/2,5mm, light reflex +/+ D
E T = 360 C (axillary)
 SECONDARY SURVEY

Head : There was burn wound grade II

A-B 6 %, hyperemis (+), edema
(+), bulla (+)
Neck : There was burn wound grade II
A-B 2 %, hyperemis (+), edema
(+), bulla (+)
Chest & Abdomen : There was burn wound
grade II A-B 17 %, hyperemis (+),
edema (+), bulla (+)
 SECONDARY SURVEY

Ekstremity :
Upper : There was burn wound grade II
A 9%, hyperemis (+), edema
(+), bulla (+)
Lower: There was burn wound grade II A
2 %, hyperemis (+), edema (+),
bulla (+)
Plan of Diagnostic

Counting blood cell

 Diagnosis

Burn Wounds Grade II A-II B

(36%)
Therapy
IVFD
Antibiotics
Analgetics
Ointment burn
Consult to general surgery
Clinical Finding
 Thank You

BAGIAN ILMU
BEDAH
stavita Maria Bandong